Labral Tears

Normal Anatomy Labrum is fibrocartilaginous ring that surrounds the acetabulum Present over the anterior, superior and posterior aspects of the acetabulum Inferior it is completed by the transverse acetabular ligament Blood supply to the outer 1/3 of the labrum Labrum has various roles Deepens the hip joint increasing joint stability Acts as a shock absorber Decreases the force transmitted to the articular cartilage by increasing the surface area of the acetabulum Provides a seal for the joint to maintain synovial fluid and pressure Hip Extension creates the most amount of contact pressure in the hip Source of proprioceptive feedback Contains nociceptors so can be a source of pain Hip joint capsule supported by 3 extra articular ligaments Pubofemoral Ischiofemoral iliofemoral

Pathology a tearing of the fibrocartilage that surrounds the acetabulum most commonly in an anterior and anterosuperior location of the inner aspect of the labrum

Mechanism of Injury Traumatic Requires significant trauma such as subluxation, dislocation or acetabular fractures shearing force from twisting, pivoting or falling External rotation force in a hyperextended position

Mechanism of Injury Insidious Microtrauma from repeated pivoting and twisting Football, hockey, golf, ballet Idiopathic Femoroacetabular Impingement Boney abnormality Capsular laxity Laxity of the capsule and ligaments decreases the ability to absorb stress Therefore labrum exposed to more stress Global Laxity Systemtic connective tissue disease Focal Rotational Laxity Golf, hockey, basketball Congenital Hip Dysplasia Shallow hip increases stress on labrum and capsule Degenerative Associated with degenerative changes within the hip joint

Classification Can be classified by location, etiology or morphology Morphological classification listed below Radial Flap Most common Disruption of the free margin of the labrum Radial Fibrillated Fraying of the free margin Associated with degenerative joint disease Longitudinal Peripheral Longitudinal tear in the peripheral aspect of the labrum Abnormally Mobile Detached labrum Similar to Bankart lesion in the shoulder

Associated Pathology Chondral lesions Osteoarthritis Dysfunctional labrum increases contact pressure on chondral surfaces Osteoarthritis Dysfunctional labrum increases the pressure within the joint leading to early deterioration Femoroactebular Impingement

Subjective Examination Usually insidious with repeated microtrauma Can be traumatic Pain in the anterior groin Worse with prolonged walking, pivoting or prolonged sitting Painful inguinal clicking May report Instability and giving way May refer pain into the buttock, greater trochanter, thigh or medial knee

Objective Examination Reduced hip extension during gait Pain, restricted range of movement or clicking on passive range of movement testing Painful hip flexion and adduction

Special Tests FABER Scour Test Resisted Straight Leg Raise

Further Investigation MRA MRI CT scan Arthroscopy

Management Conservative management attempted for 10 – 12 weeks initially Surgery is often required

Conservative Reduce pain and inflammation NSAID’s Ice Massage Rest from aggravating activities for positions (end range extension, pivoting) Restore Normal Range of Movement Lumbar spine, Hip Joint mobilisation Joint manipulation Stretches N.B stretches should not replicate clients symptoms

Conservative Restore Normal Muscle Activation Hip Flexors Hip Extensors and Abductors Deep Hip Rotators Restore Dynamic Stability Proprioceptive Training Sport Specific Training

Plan B Surgery Different types of surgery depending on arthroscopic findings and surgeon preference Arthroscopic Debridement

References Cheatham, S. W., K. R. Enseki and M. J. Kolber (2016). "The clinical presentation of individuals with femoral acetabular impingement and labral tears: A narrative review of the evidence." J Bodyw Mov Ther 20(2): 346-355. Groh, M. M. and J. Herrera (2009). "A comprehensive review of hip labral tears." Current Reviews in Musculoskeletal Medicine 2(2): 105-117. Martin, R. L., K. R. Enseki, P. Draovitch, T. Trapuzzano and M. J. Philippon (2006). "Acetabular labral tears of the hip: examination and diagnostic challenges." J Orthop Sports Phys Ther 36(7): 503-515. Reiman, M. P., R. C. Mather, 3rd, T. W. Hash, 2nd and C. E. Cook (2014). "Examination of acetabular labral tear: a continued diagnostic challenge." Br J Sports Med 48(4): 311-319. Tijssen, M., R. E. van Cingel, E. de Visser, P. Holmich and M. W. Nijhuis-van der Sanden (2016). "Hip joint pathology: relationship between patient history, physical tests, and arthroscopy findings in clinical practice." Scand J Med Sci Sports.